MEDICAL SCHEDULE OF BENEFITS – GOLD PLAN
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HMO
PROVIDERS
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PARTICIPATING PROVIDERS
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NON-PARTICIPATING PROVIDERS
(Subject to Usual and Customary Charges)
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| LIFETIME MAXIMUM BENEFIT |
Unlimited |
| CALENDAR YEAR MAXIMUM BENEFIT |
Unlimited |
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CALENDAR YEAR DEDUCTIBLE
Single
Family
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$0
$0
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$250
$500
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$500
$1000
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CALENDAR YEAR OUT-OF-POCKET MAXIMUM
(excludes Deductible)
Single
Family
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$1000
$2000
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$2000
$4000
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$3000
$6000
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MEDICAL BENEFITS
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Allergy Services (all)
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100%
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80% after Deductible
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60% after Deductible
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Ambulance Services
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80%
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80% (Deductible waived)
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Paid at Participating Provider level of benefits
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Ambulatory Surgical Center
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$125 Copay then 90%
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80% after Deductible
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60% after Deductible
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Chiropractic Care/Spinal Manipulation
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$20 Copay then 100%
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80% after Deductible
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70% after Deductible
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Diagnostic Testing, X-Ray and Lab Services (Outpatient)
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90%
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80% after Deductible
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60% after Deductible
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Durable Medical Equipment (DME)
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80%
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80% after Deductible
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60% after Deductible
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Emergency Room Services
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$100 Copay then 100%
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$100 Copay then 80% (Deductible waived)
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$100 Copay then 70% (Deductible waived)
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NOTE: The Copay will be waived if the person is admitted directly as an Inpatient to the Hospital.
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Home Health Care
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80%
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80% after Deductible
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60% after Deductible
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Calendar Year Maximum Benefit
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100 visits
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Hospice Care
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90%
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80% after Deductible
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60% after Deductible
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Hospice Bereavement Counseling
(within 6 months of Covered Person's death)
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90%
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80% after Deductible
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60% after Deductible
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Hospital Expenses or Long-Term Acute Care Facility/Hospital
(facility charges)
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Inpatient
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$250 Copay per admission then 90%
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80% after Deductible
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60% after Deductible
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Room and Board Allowance
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Semi-Private Room rate*
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Semi-Private Room rate*
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Semi-Private Room rate*
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Intensive Care
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$250 Copay per admission then 90% ICU/CCU Room rate
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80% after Deductible ICU/CCU Room rate
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60% after Deductible ICU/CCU Room rate
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Miscellaneous Services & Supplies
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90%
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80% after Deductible
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60% after Deductible
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Outpatient
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90%
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80% after Deductible
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60% after Deductible
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* A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered at 80% of the least ex pensive rate for a single or private room.
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Infertility*
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90%
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80% after Deductible
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60% after Deductible
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* Benefits are limited to initial exam and diagnostic testing.
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Maternity (Prenatal, Delivery and Postnatal)
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90%
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80% after Deductible
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60% after Deductible
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Mental Disorders and Substance Use Disorders
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Inpatient
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$250 Copay per
admission then 90%
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80% after Deductible
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60% after Deductible
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Outpatient
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$20 Copay then 100%
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$30 Copay then 100%
(Deductible waived)
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60% after Deductible
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Emergency Care (ambulance and Emergency Room)
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$100 Copay, then 100%
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$100 Copay, then 100%
(Deductible waived)
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$100 Copay, then 100%
(Deductible waived)
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Occupational Therapy (OT) (Outpatient)
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80%
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80% after Deductible
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60% after Deductible
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Physical Therapy (PT) (Outpatient)
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80%
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80% after Deductible
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60% after Deductible
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Physician's Services
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Inpatient/Outpatient Services
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90%
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80% after Deductible
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60% after Deductible
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Office Visits
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$20 Copay then 100%*
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$30 Copay then 100% (Deductible waived)*
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60% after Deductible
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Physician Office Surgery
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100%
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80% after Deductible
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60% after Deductible
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*Copay applies to the Physician office visit component only. All other services are paid subject to any Deductible and Coinsurance percentages. For HMO Providers, there is no additional cost to the Covered Person once the $20 Copay is paid.
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Private Duty Nursing
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80%
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80% after Deductible
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60% after Deductible
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Prosthetics and Orthotics
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80%
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80% after Deductible
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60% after Deductible
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Routine Care
(includes but is not limited to routine physicals, well child care, immunizations, tine test, flu shots, and B-12 injections)
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Routine Colorectal Cancer Examination (including related laboratory test)
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100%
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100% (Deductible waived)
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60% after Deductible
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Calendar Year Maximum Benefit
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1 examination
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Routine Mammogram
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90%
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80% (Deductible waived)
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60% after Deductible
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Maximum Benefit Ages 35-39
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1 baseline procedure
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Maximum Benefit Ages 40 and over
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1 procedure per Calendar Year
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Routine Pap Smear
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100%
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100% (Deductible waived)
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60% after Deductible
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Calendar Year Maximum Benefit
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1 pap smear
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Routine Pelvic Examination
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100%
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100% (Deductible waived)
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60% after Deductible
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Calendar Year Maximum Benefit
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1 examination
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Routine PSA
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100%
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100% (Deductible waived)
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60% after Deductible
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Calendar Year Maximum Benefit
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1 test
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Routine Care – All Other
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100%
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100% (Deductible waived)
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Not Covered
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NOTE: Flu shots rendered by Randolph County Health Department will be covered at 100% (Deductible waived).
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Routine Eye Examination
(includes refraction)
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100%
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100% (Deductible waived)
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Not Covered
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Calendar Year Maximum Benefit
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1 examination
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Skilled Nursing Facility and Rehabilitation Facility
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80%
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80% after Deductible
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60% after Deductible
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Combined Calendar Year Maximum Benefit
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100 days
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Speech Therapy (ST) (Outpatient)
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80%
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80% after Deductible
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60% after Deductible
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Temporomandibular Joint Dysfunction (TMJ)
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90%
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80% after Deductible
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60% after Deductible
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Transplants
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100%
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$1,000 Copay per
transplant then 80%
(Deductible waived)
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Not Covered
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Urgent Care Facility
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$35 Copay then 100%
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$50 Copay then 80%
(Deductible waived)
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Not Covered
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Copay applies to the Physician office visit component only. All other services are paid subject to any Deductible and Coinsurance percentages. For HMO Providers, there is no additional cost to the Covered Person once the $20 Copay is paid.
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Vision Care – Hardware (up to age 19)
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100%
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100% (Deductible waived)
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60% after Deductible
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Maximum Benefit
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1 pair of lenses per Calendar Year and 1 pair of frames every 2 Calendar Years; OR 1 pair of contact lenses per Calendar Year
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NOTE: A Covered Person may receive one pair of lenses or one pair of contact lenses per Calendar Year. Disposable contacts will not be subject to the "one pair of lenses" maximum.
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All Other Eligible Medical Expenses
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90%
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80% after Deductible
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60% after Deductible
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